The latter two factors hardly seem like clinical criteria on which to base the decision,
but the problem is, there are no such criteria. Experts identify myriad factors that
go into decisions about ICU admission, including what the hospital or ED protocols
are, how comfortable hospitalists are handling sicker patients, how many beds are
available, and who is the ultimate decider.

“This problem just defies standardization, by which I mean there is never going
to be such a thing as a set of agreed-upon ICU admission and discharge criteria,”
said Jeremy Kahn, MD, MS, a critical care physician at the University of Pittsburgh
Medical Center. “It's just too fungible—the notion of who needs an intensive
care unit. Obviously, people who are on life support, like a mechanical ventilator,
or vasopressor certainly need admission to the ICU, but outside of that, predicting
the true need for intensive care has just proven to be impossible.”

“There are so many stakeholders involved, and they have different voices at
different institutions,” noted Meeta Prasad Kerlin, MD, MS, a critical care
specialist at the University of Pennsylvania in Philadelphia. “The institutional
decisions about what resources they are going to have on the floors are going to differ,
and they may be based on reimbursement strategies or they may be based on sort of
who has the loudest voice when there's a conflict or something like that.”

Despite these factors, ICU clinicians and experts continue to hunt for methods to
make ICU care high quality and high value, from measuring patient outcomes to reducing
ICU beds to developing new levels of care.

Latest research

Recent research on the effects of ICU care has shown mixed results. A large, randomized
study in France found no reduction in six-month mortality after the implementation
of a program to systematically admit critically ill elderly patients to the ICU. The results, published in the Oct. 17, 2017, JAMA, refuted the hypothesis that “just being able to put more people in the ICU,
even the ones that are sort of on the margins, is going to somehow make a difference,”
said Hannah Wunsch, MD, MSc, senior scientist at Sunnybrook Health Sciences Centre
in Toronto.

Thomas Valley, MD, MSc, coauthor of that study and a pulmonologist and critical care
physician at the University of Michigan in Ann Arbor, said the overall evidence about
which patients should and shouldn't be sent to the ICU is fairly scarce. “We
really don't have a great way of assessing benefit right now.”

One issue is that mortality risk may not be the best way to measure which patients
derive the most benefit, Dr. Valley said. “A lot of the work that's been done
before has focused on an individual's risk of dying and really focused on making sure
patients with the highest risk of dying go to the ICU. That makes a lot of conceptual
sense, but it may miss patients who might have a lower risk of dying but still could
benefit greatly from going to the ICU.”

Dr. Valley is not certain how best to measure meaningful improvements in patients'
lives after ICU admission, but he expects this will be a topic of research over the
next decade.

The overarching criteria by which the medical community judges how well ICUs are being
used in the country depends on what definition is being used to decide who should
be admitted, he continued. “We're still in the process of actually trying to
figure that question out, and until we set that bar, then it's tough to say whether
we're overusing or actually underusing the ICU.”

The question of over versus underuse is closely tied to decisions about how many ICU
beds a hospital should have. “A big issue in this country is not knowing the
right number of ICU beds,” Dr. Kerlin said. “We have an order of magnitude
more ICU beds in the U.S. than some other industrialized countries in the world—we
have literally almost 10-fold more than the U.K. and we have double Canada.”

“We're starting to see a plateau finally,” Dr. Kahn said, attributing
that to decreased hospital spending on infrastructure and the movement toward health
care system consolidation. Another contribution might be strengthened efforts to collect
patients' care preferences, he speculated.

“The fewer 85-year-old patients with dementia I admit purely because nobody
has had an end-of-life discussion with them, the better,” Dr. Kahn said.

Dr. Kerlin predicts that the number of ICU beds will decrease further as administrators
and physicians learn to become more efficient and uniform with admission decisions.
“There was an estimate that our ICUs sit at about 60% to 65% occupancy at any
given time,” she said. “That means that a third of our ICU beds in the
country are not being used at any given time, which feels like a lot of waste in our
system. So I think that if we could improve our triage decisions, we could better
address that and possibly just be more efficient with our ICU utilization.”

New models of care

One potential solution to the ICU triage dilemma could be so-called intermediate care,
providing more than a general ward but less than a full-fledged ICU. There are even
fewer data on that, however.

“People are more aware of it as a piece of the model that needs to be addressed,
but it's even harder than looking at the benefits of intensive care, because of the
complexity of who comes in and out of intermediate care,” Dr. Wunsch said.

There's also the problem that intermediate care has a very heterogeneous definition.
“We don't really know at this point whether places that say they're providing
intermediate intensive care are providing essentially just telemetry, or whether they're
providing organ support such as vasopressors or noninvasive ventilation; we just don't
know what intermediate care looks like in different institutions, or even what the
nurse-to-patient ratio is in different institutions,” Dr. Wunsch observed.

“There's a lot of interest in trying to understand it better,” Dr. Kerlin
said. “We don't know if they help offload ICUs. We don't really know for sure
if they decrease costs, which might be one big motivator to open them. We don't know
if they change outcomes one way or the other—if they improve outcomes or shorten
length of stay or worsen outcomes because patients aren't getting to the ICU when
they should be.”

Dr. Kahn has concerns over this model. “Overspecializing hospital beds has
risks, and I think that it's just one more judgment decision that hospital-based physicians
have to make,” he said.

He suggested that a swing- or flex-bed system in the ICU that enables physicians to
designate patients as ready for a stepdown without having to shuffle anything around
physically might work out better.

“[This is] a really novel way where you can essentially perfectly triangulate
supply with demand as opposed to having to figure, ‘OK, I'm going to open a
stepdown unit and maybe the stepdown unit some days is going to be underfilled but
some days is going to be completely filled,’” he said. “That
to me is a frontier that is just now catching on.”

Next steps

There's some debate among the experts about whether ICU triage decisions ever will,
or should, get more protocolized.

In 2013, Dr. Wunsch predicted to ACP Hospitalist that more scientific methods of intensive care triage would be in place within six
years (see “Too many or too few: Who belongs in the ICU?” in the February 2013 issue). “We're a little bit better, but not
as far as I think most of us would have hoped,” she said now. “It's
so heterogeneous in terms of what's going on across the country. Everybody has this
optimism that we should be able to predict well and really intervene earlier and make
a difference, but it's not so clear that it's making a huge difference yet.”

Dr. Kahn is not optimistic that a system will ever be developed. “We need to
once and for all stop trying to develop objective triage criteria because that I believe
is just a waste of time. They're never going to work because if there's an ICU bed
available, people will override those triage criteria. We see that every day in the
hospital.”

The answer, instead, is in the current trend toward cutting ICU beds, he said. “There
has to be a general shift towards more value in health care both in hospital medicine
at large and in intensive care medicine, including more value-based reimbursement
policies.”

On the bright side, he thinks the physician response to these changes will be improvements
in the decision making about ICU placement. “Physicians in general are good
at triage, and the data would say that when we're forced to triage a scarce resource,
we're pretty good at triaging it on an individual, case-by-case basis,” Dr.
Kahn said.

ACP Hospitalist provides news and information for hospitalists, covering the major issues in the field. All published material, which is covered by copyright, represents the views of the contributor and does not reflect the opinion of the American College of Physicians or any other institution unless clearly stated.